Case Hypertension and Chest Pain

7/30/2019 Case Hypertension and Chest Pain

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CASE STUDY


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A 55 y.o man complained of chest discomfort when exercising sincethe last 2 months.. He admitted suffering from both hypertensionand DM2 . No history of MI, CHD or stroke. He is a heavy smoker.Currently he is on Glibenclamide 5 mg (1-0-) and Rampiril 1 x 10mg.

BP 150/90 mmHg HR 78/m

ECG : SR, LVH

LDL 126 mg/dL, TG 144 mg/dL. The kidney function and liver

function are normal

01 Case Study


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02 What are the Patients Problem?

1. Cigarette smoker

2. Hypertension

3. Diabetes Mellitus

4. Dyslipidemia

5. Chest discomfort


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03 What are the Patients Problem?

Cigarette smoker

Hypertension

Diabetes Mellitus

Dyslipidemia

Chest discomfort

YesYes

Yes

Yes

Yes !


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Is there any way to preventcardiovascular event,considering CVD is the leadingcauses (67%)1 of morbidity and

mortality among Hypertensionand DM patients?

04

1. Alexander CM, Antonello S. Pract Diabet. 2002;21:21-8 2. Colhoun HM et al. Lancet. 2004;364:685-696

A. Yes

B. No


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Is there any way to preventcardiovascular event,considering CVD is the leadingcauses (67%)1 of morbidity and

mortality among Hypertensionand DM patients?

05

Yes

1. Alexander CM, Antonello S. Pract Diabet. 2002;21:21-8 2. Colhoun HM et al. Lancet. 2004;364:685-696


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ACS

Coronary

Thrombosis

Myocardial

Ischemia

CAD

Atherosclerosis

Risk Factors

( Dyslipidemia, BP, DM,Insulin Resistance, Platelets,

Fibrinogen, etc) Adapted fromDzau et al. Am Heart J. 1991;121:1244-1263

The cardiovascular continuum of events

Arrhythmia andLoss of Muscle

Remodeling

Ventricular

Dilatation

Congestive

Heart Failure

End-stage

Heart Disease

Primaryprevention

Secondaryprevention Stroke

Important


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8

Progression of HT to LVH to HF


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BAGAIMANA PASIEN HARUS DIKELOLA?

06

Tentukan risiko pasien ini. Bagaimana caranya?Apakah perlu diperiksa marker untuk sindrom

koroner akut?


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Category Systolic Diastolic

Optimal


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Assessment of the overall cardiovascular risk

Cardiovascular Risk Factors

Presence of Risk Factors

- Increasing age- Male gender- Smoking- Family history of premature cardiovascular disease (age< 55 in men and

< 65 in women)

- Dyslipidemia- Sedentary lifestyle

- Unhealthy eating- Abdominal obesity- Dysglycemia (diabetes, impaired glucose tolerance, impaired fasting

glucose)

Presence of Target Organ Damage- Microalbuminuria or proteinuria

- Left ventricular hypertrophy- Chronic kidney disease (glomerular filtration rate < 60 ml/min/1.73 m2)

Presence of atherosclerotic vascular disease- Previous stroke or TIA- Coronary Heart Disease- Peripheral arterial disease

CV Risk Factors that may alter thresholds and targets in the treatment of HTN2009 CHEP Recommendations


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CKMB dan Troponin dalam batasnormal

Adakah pemeriksaan lain diperlukan?


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13

Chest PA view of Heart - LVH

C/T ratio > 50%


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Click to edit Master title styleClick to edit Master title styleBAGAIMANA RISIKO PASIEN INI?

RENDAH ?

SEDANG ?

TINGGI?

SANGAT TINGGI ?


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Very high

added risk

High

added risk

High

added risk

High

added risk

Moderate

added risk

3 risk factors,

mets, organdamage, or diabetes

Very high

added risk

Very high

added risk

Very high

added risk

Very high

added risk

Very high

added risk

Established CV or

renal disease

Very highadded riskModerateadded riskModerateadded riskLow addedriskLow addedrisk1-2 risk factors

High added

risk

Moderate

added risk

Low added

risk

Average

risk

Average

riskNo other risk factors

Grade 3 HTGrade 2HT

Grade 1HT

Highnormal

NormalOther risk factor,

organ damage, ordisease

Blood pressure (mm Hg)

HT: hypertension; mets: metabolic syndrome; CV: cardiovascular

Mancia G, et al. 2007 ESH/ESC Guidelines for the Management of Arterial Hypertension. J Hypertens 2007;25:1105-1187

Cardiovascular Risk Stratification


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Click to edit Master title styleClick to edit Master title styleBAGAIMANA SEHARUSNYA PASIEN INI DIKELOLA?

Merokok

Hypertensi Diabetes Mellitus

Dyslipidemia

Chest discomfort

Obat Anti-hypertensive

Stop Merokok Merubah

gaya hidup

Obat Hypoglicaemic

Obat Hypolipidemic

Obat anti-hipertensi

Obat anti iskemia


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Hypertension and subcinical organ damage

data obtained in the LIFE study, in which hypertensivepatients in whom treatment was accompanied byregression of echocardiographic

LVH or a delayed increase in LVM had less

incident cardiovascular events, including sudden death,than those in whom no regression from or earlierprogression to LVH occurred.

Mancia et al Reappraisal of ESC/ESH 2007 Guidelines on Hypertension


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Cardiac Hypertrophy in Hypertension

Cardiac hypertrophy (LVH)

1. Regression of cardiac hypertrophy leads to animprovement in prognosis.

2. Any antihypertensive drug can induce the regression ofcardiac hypertrophy by maintaining a sufficient decrease inblood pressure. The target of blood pressure controlshould be


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Hypertension and coronary heart disease

1. Careful and sufficient reduction of blood pressure is important

in coronary artery disease. The target of blood pressure control shouldbe


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Whats New for 2009The Hypertensive Diabetic

Patients with diabetes are at high cardiovascularrisk

Up to 80% of diabetic patients die of cardiovascular

disease Most patients with diabetes have hypertension

Between 35 and 75% of diabetic complicationshave been attributed to hypertension.

Treatment of hypertension in patients with

diabetes reduces total mortality, myocardialinfarction, stroke, retinopathy and progressiverenal failure rates.

More intensive reduction in blood pressurereduces major cardiovascular events and totalmortality by 25%

Treating hypertension in the diabetic patient reduces death and disability and reduces

health care system costsTARGET


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Blood Pressure Evidence: Primary Prevention

0 1 2 3 4 5 6 70

.04

.08

.12

.16

.20

RR (95% CI) P-value

A/C 0.98 (0.90-1.07) 0.65

L/C 0.99 (0.91-1.08) 0.81RateofM

Ior

fatalCH

D

Antihypertensive and Lipid-Lowering Treatment to Prevent

Heart Attack Trial (ALLHAT)

ALLHAT Investigators. JAMA 2002;288:2981-97

Years to CHD Event

BP=Blood pressure, CHD=Coronary heart disease,HTN=Hypertension, MI=Myocardial infarction

Chlorthalidone

Amlodipine

Lisinopril

33,357 patients with HTN and >1 CHD risk factor randomized to chlorthalidone, amlodipine, orlisinopril for 5 years

There is similar efficacy among BP lowering agents


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0 6 12 18 24 30 36 42 48 54 60 66

Study Month

4

8

12

16

0ProportionwithCV

death,

MI,orstroke(%)


Losartan Intervention for Endpoint (LIFE) Reduction in

Hypertension Study

Dahlf B et al. Lancet2002;359:995-1003

AtenololLosartan

13% RRR, P=0.021

ARB=Angiotensin receptor blocker, CV=Cardiovascular,

DBP=Diastolic blood pressure, LVH=Left ventricular hypertrophy,

MI=Myocardial infarction, SBP=Systolic blood pressure

*Defined by SBP=160-200 mmHg or DBP=95-115 mmHg

9,193 high-risk hypertensive* patients with LVH randomized to losartan (100 mg) or atenolol(100 mg) for 5 years

An ARB provides greater efficacy in patients with LVH


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Anglo-Scandinavian Cardiac Outcomes TrialBlood Pressure

Lowering Arm (ASCOT-BPLA)


NonfatalMI

and

fatalCHD(

%)

6

2

4

0

1 2 3 4 5 60

Time since randomization (years)

RRR = 10%, P = 0.1052

Atenolol-based regimen

Amlodipine-based regimen

Dahlf B et al. Lancet2005;366:895-906

BP=Blood pressure, CV=Cardiovascular, CHD=Coronaryheart disease, MI=Myocardial infarction

19,342 high-risk hypertensive patients with 3 additional CV risk factors randomized toamlodipine (10 mg) & perindopril (8 mg) or atenolol (100 mg) & bendroflumethiazide (2.5

mg) for 5.5 years

There is similar efficacy with both BP lowering regimens


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HOPE Study (Usefulness of ACEi)Relative Risk Reduction of Cardiovascular Endpoints in high riskpatients (angina, DM, HTN, PAOD) with normal LV Fx.

CombinedCardiovascular

endpointsCardiovascular

mortalityMyocardialinfarction

Stroke

-22% p


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Favors valsartan Favors amlodipine

Primary cardiac composite endpoint

Cardiac mortality

Cardiac morbidity

All myocardial infarction

All congestive heart failure

All stroke

All-cause death

New-onset diabetes

0.5 1 2

Blood Pressure Evidence: Secondary Prevention

Valsartan Antihypertensive Long-Term Use Evaluation (VALUE) Trial

Julius S et al. Lancet2004;363:2022-2031

ARBS=Angiotensin receptor blocker, CCB=Calciumchannel blocker, CV=Cardiovascular

15,245 patients with untreated HTN and high CV risk randomized to a BP

lowering strategy with valsartan (160 mg) or amlodipine (10 mg) for 4.2 years

There is similar efficacy with an ARB and CCB


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Nissen S et al. JAMA 2004;292:2217-26

Blood Pressure Evidence: Secondary Prevention

Comparison of Amlodipine vs Enalapril to Limit Occurrences of

Thrombosis (CAMELOT) Trial

*Includes CV death, myocardial infarction, cardiac arrest, coronary revascularization, hospitalization for heart

failure or angina pectoris, stroke, transient ischemic attack, development of peripheral arterial disease

CVevent

rate*

0

0.25

0.20

0.10

0.05

6 12 18 24

0.15

0

Placebo

Amlodipine

Enalapril

Months

Follow-up BP

(mmHg)

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BP=Blood pressure, CAD=Coronary artery disease,CV=Cardiovascular, DBP=Diastolic BP

1,991 patients with CAD and a DBP


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2,028 patients with symptomatic HF, LVSD (EF


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ARB Evidence: Secondary Prevention

Pfeffer M et al. NEJM2003;349:1893-1906

Valsartan in Acute Myocardial Infarction Trial (VALIANT)

0.0

0.1

0.2

0.3

0.4

0 6 12 18 24 30 36

Valsartan

Valsartan and Captopril

Captopril

AllC

auseMo

rtality

Months

Valsartan vs. Captopril: HR = 1.00; P = 0.982

Valsartan + Captopril vs. Captopril: HR = 0.98; P = 0.726

ACE-I=Angiotensin converting enzyme inhibitors,

ARB=Angiotensin receptor blockers, EF=Ejection

fraction, LVSD=Left ventricular systolic dysfunction

14,703 patients with post-MI HF or LVSD (EF


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Anglo-Scandinavian Cardiac Outcomes TrialLipid Lowering Arm (ASCOT-LLA): StudyDesign

Nonfatal MI, including silent MI, and fatal CHD

Primary efficacy end point

HTN=hypertension; SBP=systolic blood pressure; DBP=diastolic blood pressure; TC=total cholesterol;

CVD=cardiovascular disease.

Sever PS et al. Lancet. 2003;361:1149-1158.

Men and women aged40-79 years

Untreated HTN(SBP 160 mm Hg,DBP 100 mm Hg, or both)

Treated HTN(SBP 140 mm Hg,DBP 90 mm Hg, or both)

TC 251.4 mg/dL

At least 3 additional

CVD risk factors

Atorvastatin 10 mg(n=5168)

Placebo

(n=5137)

Patient population

5 years

19,342

patients

with HTN

10,305

patients with

TC 251.4 mg/dL

Trial stopped at 3.3 years,

2 years earlier than expected


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RRR=relative risk reduction.

Adapted from Sever PS et al. Lancet. 2003;361:1149-1158.

ASCOT-LLA: Atorvastatin Reduced theOccurrence of First Major CV Events

4

0

1

2

3

0.0 0.5 1.0 1.5 2.0 2.5 3.0 3.5

Years

36% RRR in

nonfatal MI and

fatal CHD

P=.0005

Atorvastatin(10 mg)

Placebo

PatientswithnonfatalMIand

fatalCHD

(%)


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Click to edit Master title styleClick to edit Master title styleBaseline Characteristics JIKEI

Clinicalcharacteristics

Valsartan arm(n=1,541)

Non-ARB arm(n=1,540)

Male 1,020 (66%) 1,023 (66%)

Female 521 (34%) 517 (34%)

Age (years) 65 (10) 65 (10)

Current smoker 259 (17%) 262 (17%)

Systolic BP [SBP]

(mmHg) 139.2 (11.4) 138.8 (10.6)

Diastolic BP [DBP](mmHg) 81.4 (10.5) 81.4 (10.8)

Heart rate (beats/min)

BMI (kg/cm2)

71 (11)

24(3)

72 (11)

24(3)

Note: Data are mean (Standard Deviation) or Number (%)


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Click to edit Master title styleClick to edit Master title styleMedical History at Baseline

Concomitant Diseases

Valsartan arm

(n=1,541)

Non-ARB arm

(n=1,540)

Hypertension 1,358 (88%) 1,341 (87%)

Coronary heart disease 514 (33%) 522 (34%)

Heart failure 176 (11%) 174 (11%)

Hyperlipidaemia 812 (53%) 813 (53%)

Diabetes mellitus 315 (20%) 314 (20%)


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Click to edit Master title styleClick to edit Master title styleEffect of Treatment on Endpoints JIKEI STUDY

Primary endpo intComposite endpoint

Secondary endpoints

Stroke/TIA

Myocardial infarction

Hospitalisation for angina pectoris

Hospitalisation for Heart Failure

Dissecting aortic aneurysm

Transition to dialysis, doubling

of serum creatinine levels

All cause mortality

Cardiovascular mortality

0.0002

0.0280

0.7545

0.0001

0.0293

0.0340

0.8966

0.7537

0.9545

P-value

TIA = transient ischaemic attack

Incidence increasedIncidence of endpoint reduced

0.125 0.25 0.5 1 2 4


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Click to edit Master title styleClick to edit Master title stylePrimary Endpoint

0 6 12 18 24 30 36 42 48

Number at risk

Valsartan 1,541 1,504 1,441 1,257 1,092 855 689 368 368

Non-ARB 1,540 1,502 1,447 1,262 1,075 835 657 344 343

15

10

5

0

Eventrate

(%)

Valsartan arm (92 events)

Non-ARB arm (149 events)

HR=0.61, p=0.0002

95% CI 0.470.79

39%


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Click to edit Master title styleClick to edit Master title styleHospitalisation for Angina Pectoris

0 6 12 18 24 30 36 42 48

Number at risk

Valsartan 1,541 1,504 1,441 1,257 1,092 855 689 368 368

Non-ARB 1,540 1,504 1,450 1,265 1,078 837 658 343 343

4

3

2

1

0

Eventrate

(%)

Valsartan arm 19 events

Non-ARB arm 53 events

HR=0.35, p=0.000195% CI 0.200.58

65%

Source: Kaplan Meier Curve adopted from Dr Dahlof ESC 2006 Hotline presentation


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Click to edit Master title styleClick to edit Master title styleHospitalisation for Heart Failure

0 6 12 18 24 30 36 42 48

Number at risk

Valsartan 1,541 1,504 1,441 1,257 1,093 856 690 369 368

Non-ARB 1,540 1,502 1,448 1,264 1,077 837 657 343 343

2.5

2.0

1.5

1.0

0.5

0.0

Eventrate

(%)

Valsartan arm 19 events

Non-ARB arm 36 events

HR=0.53, p=0.029

95% CI 0.310.94

47%

Source: Kaplan Meier Curve adopted from Dr Dahlof ESC 2006 Hotline presentation


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Phase ofTreatment

Acute

treatment

Secondaryprevention

Overall

Total #Patients

28,970

24,298

53,268

0.5 1.0 2.0

RR of deathb-blocker

better

RR (95% CI)

Placebo

better

0.87 (0.77-0.98)

0.77 (0.70-0.84)

0.81 (0.75-0.87)

b-blocker Evidence: Secondary Prevention

Antman E, Braunwald E. Acute Myocardial Infarction.

In: Braunwald E, Zipes DP, Libby P, eds. Heart Disease:

A textbook of Cardiovascular Medicine, 6th ed.,

Philadelphia, PA: W.B. Sanders, 2001, 1168.

Summary of Secondary Prevention Trials ofb-blocker Therapy

CI=Confidence interval, RR=Relative risk


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ASPIRIN IN HYPERTENSION

the prudent recommendations of the 2007 ESH/ESC guidelines can bereconfirmed: antiplatelet therapy, in particular low-dose aspirin, shouldbe prescribed to hypertensive patients with previous cardiovascularevents;

it can also be considered in hypertensive patients without a history ofcardiovascular disease with reduced renal function or with a highcardiovascular risk.

In patients receiving aspirin, careful attention should always be given to theincreased possibility of bleeding,particularly gastrointestinal.

Mancia et al. Reappraisal of 2007 ESC/ESH Guidelines on Hypertension


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2nd Prevention of aspirin

- CV death 17% - AMI 34%

- CVA 35%

- All CV disease 35%

AHA ecommendation :Anyone with atherosclerosis

Initial Tx: 160-325mg at 1st day

Subsequent Tx: 75-160 mg/day


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Anti-anginal Drug


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Click to edit Master title styleClick to edit Master title styleJADI, BAGAIMANA GARIS BESAR PENGOBATAN?

ASPIRIN / ANTIPLATELET ?

THIAZIDE

BETA BLOCKER

CALCIUM CHANNEL BLOCKER

NITRAT

ACE-INHIBITOR

ARB

VASODILATOR LAIN

ANTI DIABETIK

HIPOLIPIDEMIK

LAIN-LAIN ?

Terapi Kombinasi


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Click to edit Master title styleClick to edit Master title styleADAKAH PEMERIKSAAN LAIN YANG DIPERLUKAN?

Laboratorium : ??

Treadmill Test ?

Ekhokardiogram

MSCT ?

Angiografi koroner/kateterisasi jantung ?

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Case Hypertension and Chest Pain